Clonal Evolution in Myelodysplastic Syndromes: From Molecular Pathogenesis to Targeted Therapeutic Strategies

Clinical Question BoxHow does clonal evolution influence prognosis and therapeutic decision-making in patients with myelodysplastic syndromes?Clonal evolution underlies the biological heterogeneity, disease progression, and treatment resistance observed in myelodysplastic syndromes.The accumulation and selection of genetic abnormalities shape clonal architecture, influencing prognosis and response to therapy.High-risk mutations and co-mutation patterns identify potential beneficiaries from early aggressive approaches, including targeted therapy or allogeneic stem cell transplantation.Molecular prognostic models such as the IPSS-M improve risk stratification by incorporating genetic data, but their static nature limits the prediction of disease trajectory, highlighting the importance of dynamic, longitudinal molecular monitoring to guide individualized treatment decisions.